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Empirical Ethics

Clinical Ethics
2019, Vol. 14(1) 33–41
Gender and cultural understandings in ! The Author(s) 2019
Article reuse guidelines:
medical nonindicated interventions: sagepub.com/journals-permissions
DOI: 10.1177/1477750919836642
A critical discussion of attitudes toward journals.sagepub.com/home/cet

nontherapeutic male circumcision and


hymen (re)construction

Gily Coene1 and Sawitri Saharso2

Abstract
Hymen (re)construction and nontherapeutic male circumcision are medical nonindicated interventions that give rise to
specific ethical concerns. In Europe, hymen (re)construction is generally more contested among medical professionals
than male circumcision. Yet, from a standard biomedical framework, guided by the principles of autonomy, beneficence,
nonmaleficence, and justice, circumcision of boys is, as this article explains, more problematic than hymen (re-) con-
struction. While there is a growing debate on the acceptability of infant circumcision, in the case of competent minors
and adults the surgery is not questioned. In the case of hymenoplasty, usually requested by a competent patient, it is
recommended to only perform the operation after extensive counseling and if there are compelling conditions.
The article further explores why attitudes of medical professionals toward both surgeries diverge and seeks to explain
how this is largely informed by gendered and socio-cultural understandings. The article further raises critical questions
on medical paternalism and the role of counseling.

Keywords
Gender, culture, male circumcision, hymen (re)construction, ethical decision-making, medicine

Introduction medical ethics, medical professionals, and associations


Hymen (re)construction—also described as hymeno- largely agree that decisions in medicine should be
plasty, hymenorrhaphy, hymen repair, or revirgina- guided by the principles of autonomy, beneficence,
tion—and male circumcision—typically the removal nonmaleficence, and justice, as devised in the classical
of part or all of the penile foreskin—are medical sur- work of Beauchamp and Childress.6 Yet, as we aim
geries that give rise to specific ethical concerns. to demonstrate, assessing both surgeries within this
Both surgeries are usually performed for cultural and framework displays some puzzling inconsistencies.
religious reasons, although in rare cases circumcision This article first outlines the main ethical issues that
can also be medically indicated.1,2 While hymenoplasty arise in scholarly debates on hymen (re)construction and
male circumcision. As these are not only discussed in
is usually requested by the patient herself, male circum-
cision is mainly performed on infants and boys upon
parental request. While the latter is an irreversible 1
Faculty of Arts & Philosophy, RHEA – Centre of Excellence on Gender,
intervention, hymenoplasty has no lasting bodily
Diversity and Intersectionality, Vrije Universiteit Brussel, Brussel, Belgium
effects. Yet, nontherapeutic circumcision is widely per- 2
Universiteit voor Humanistiek, Utrecht, Netherlands
formed and accepted, while hymenoplasty is a much
more controversial technique and medical professio- Corresponding author:
Gily Coene, Faculty of Arts & Philosophy, RHEA – Centre of Excellence
nals in Europe are mostly against it.3–5 on Gender, Diversity and Intersectionality, Vrije Universiteit Brussel,
This raises critical questions about why these two Pleinlaan 2, Brussel 1050, Belgium.
surgeries are regarded so differently. Scholars in Email: gily.coene@vub.be
34 Clinical Ethics 14(1)

medical ethics, we reviewed publications that were select- the literature are temporary hymen suture and hyme-
ed from medical (PubMed and Medline Database), noplasty.11,18 The first method comes down to applying
sociologically, culturally, and philosophically oriented a few stitches in the remnants of the hymen, resulting in
databases, including the Social Sciences Citation Index, a small opening. As the stitches hold their tensile
Academic Search Elite (EBSCOhost), Sociological strength for only about a week, this method is only
Abstracts (Illumina), and Philpapers.7 Next, we explore suited for women who intend to have the wedding
how standard ethical principles apply to both surgeries within that week. The second method is more lasting
and conclude that the divergent attitudes toward both and requires real wound healing of the hymen.
surgeries also rely on gendered socio-cultural under- Both methods are done under local anesthesia and
standings and the different symbolic meanings that are patients are discharged on the day of the surgery.
attributed to both surgeries. In some countries, medical associations have devel-
This article does not discuss the foundations or use- oped guidelines on hymen surgery. According to the
fulness of a principled ethical framework, nor does it Dutch Society of Obstetrics and Gynecology, hymen
engage with debates on whether such frameworks are (re)construction should not be performed, unless it
cross-culturally applicable or theoretical issues about appears, after counseling, that no other option offers
moral universalism and the foundations of normative a solution. Detailed instructions are given about what
ethics. It is assumed that such frameworks are largely the counseling should entail. In case the request for
accepted to guide clinical practice. Yet, by pointing out help is inconsistent with the physician’s personal
how socio-cultural understandings impact on ethical views, the patient should be referred to someone else.19
decisions, it aims to stimulate a more critical under- Some surveys further show that the surgery is a
standing of ethical decision-making in clinical practice. very contested practice among medical professionals.
In Sweden, almost half (46.9%) of the consulted GPs
and gynecologists fully agreed with the statement
Hymen(re)construction: Sexual that under no circumstance physicians should write a
autonomy and double standards virginity certificate and similarly 42% agreed that they
never should perform a hymen restoration. The others
In many countries around the world, and contrary to
agreed that under certain conditions, they would be pre-
Western popular belief not only in Muslim cultures, the
pared to assist with this. The researchers conclude that
norm is that women abstain from premarital sex.8–11 An
the main value conflict experienced by the respondents is
intact hymen and loss of blood during sexual intercourse
“on the one hand helping patients in distress (or saving
in the wedding night is traditionally considered as proof
lives) and on the other hand the importance of standing
of virginity. Yet, many women do not bleed when they
up against suppressive and patriarchal norms.”20
have intercourse for the first time12 and the hymen is
Another Swedish survey that included not only gynecol-
not, as is often believed, a membrane separating the ogists and midwives, but also youth welfare and social
vagina from the outside world, but “a thin, bloodless, officers suggests that this value conflict is experienced
elastic mucosa surrounding the opening of the vaginal more generally among Swedish health practitioners.3
introitus.”11 This piece of mucosa can also be ruptured In the Netherlands 73% of the surveyed gynecologists
by doing sport, or by inserting a tampon, and, because said they would never perform a hymen (re)construc-
of its elasticity does not have to show signs of deflora- tion.21 In Switzerland, a questionnaire was sent to 100
tion after penetration. Therefore, it is a myth that doc- clinics for gynecology in public hospitals. While a
tors can establish whether a young woman is still a minority (16.7%) refused to perform a hymen (re)con-
virgin.13,14 Although there is technically not necessarily struction, more than half of the clinics (64.3%) reported
a perforated membrane to restore, physicians get that they always (28.6%) or mostly (35.7%) granted the
requests to perform a surgery to restore the hymen. In request.5 In a study that surveyed the views on hymen
communities in which premarital virginity is expected, (re)construction from midwives, predominantly from
the consequences when a young woman is suspected of Europe, the majority of the respondents (86%) agreed
having lost her virginity can be severe, both for herself with the statement that virginity examinations and
and for her family. In Turkey, the most frequent cause hymen operations are part of violence against women
of attempted suicide among young women is hymen and only 8% believed hymen (re)construction is justifi-
examination15 and hymen (re)constructions are said to able.22 A survey among gynecologists in Flanders
have reduced the number of honor killings in Egypt.16 (Belgium) showed that they were very divided about
Throughout Europe hymen (re)constructions are whether hymen (re)construction violated the right to
performed in hospitals and private clinics, usually physical integrity of the woman; roughly a third
after (more or less extensive) counselling.3,5,14,17,18 agreed, a third was neutral, and a third disagreed.18
The most common methods of surgery described in The study also asked whether physicians had actually
Coene and Saharso 35

received a request for hymen (re)construction. Of those outweigh arguments contra. Regarding hymen (re)con-
who had, half of them (52.5%) had performed the pro- struction as deceit, Pablo de Lora26 discusses a
cedure. The most frequently mentioned arguments to common objection against the deception argument: if
comply with the woman’s request were respecting her hymen (re)construction is wrong, because it is deceit,
autonomy (65.3%) and the risky situation in which then all cosmetic surgery is unethical. De Lora, howev-
she was involved (44.9%). For those who decided not er, thinks hymen (re)construction is not like any other
to perform the surgery their main reasons were that it form of cosmetic surgery. Normally, the plastic sur-
was not a medically indicated procedure (41.5%), geon actually does change the appearance of a nose,
because it would keep up the virginity myth (45.3%) breast, or belly. In that sense, it is no deceit, but a
and also the double sexual standards (49.1%). Almost transformation; the deceit is in not telling that this
half of them (49.1%) considered the procedure a viola- new appearance is not given by nature. Hymen (re)con-
tion of the patient’s bodily integrity. struction, however, does not restore chastity. The sur-
The referred to guidelines and surveys indicate gery helps the woman to convince someone else that
that, generally, medical professionals condemn the she is still a virgin. Therefore, hymen (re)construction is
virginity rule as infringing on the sexual autonomy of according to De Lora a form of deceitful cosmetic sur-
women and as representing double sexual standards. gery, which makes the physician an accomplish in an
Therefore, and also because the procedure is not med- act that is wrong. Yet, there may be other things to
ically indicated, they believe hymen (re)construction consider that justify performing the surgery.26 Alain
should not be performed. Some see the surgery as Vande Putte27 refers to these “other things” when argu-
also infringing on the patient’s bodily integrity. If nev- ing that showing respect for the autonomy and bodily
ertheless some physicians are in favor of operating, this integrity of the patient “may override considerations of
is because they wish to respect the woman’s autonomy truthfulness towards third parties interested in control-
and take into account the reprisals they expect the ling these aspects of the patient’s life.” Another over-
woman has to face. Even the Dutch guidelines that riding concern is formulated by Lee Seng Khoo and
go furthest in meeting the woman’s needs, with their Vasco Senna-Fernandes,28 who believe that physicians
many provisos and the extensive counseling that is should refrain from moral judgment:
required, make clear that the Dutch professionals
only grudgingly agree to perform the surgery. We have to understand the human need to belong, to
Common ethical arguments contra hymen (re)con- be accepted and loved by their subcultural group with
struction are that there is no medical indication, that their own values and beliefs. We cannot attack others’
performing the operation is becoming an accomplish in religious beliefs even if they conflict with our own and
deceit, that the operation contributes to keeping up the cannot violate basic human rights by withholding med-
myth that all women have a hymen that bleeds with the ical or surgical treatment.
first coitus, that it perpetuates gender inequality, that it
amounts to discrimination of women and violates Comparing hymen (re)construction and bloodless treat-
women’s right of autonomy and their right to bodily ment for Jehovah’s Witnesses, Niklas Juth and Niels
integrity. Monika Christianson and Carola Eriksson22 Lynøe29 also discuss how the medical profession should
for instance argue that “virginity control and hymen deal with requests for medical treatments that follow
‘reconstructions’ are elements of patriarchy, whereby from minority cultural or religious beliefs. For
violence and control are employed to subordinate Jehovah’s Witnesses blood transfusions are prohibited
women.” They recognize that if the woman’s life is at by their religion and to avoid sanctions, patients from
stake hymen (re)constructions may be justifiable, but this religion therefore ask for bloodless treatment, i.e.
generally they consider hymen (re)construction as an medical interventions that are not routinely offered to
instrument in the control of women’s sexuality and patients in healthcare. When discussing whether hymen
therefore an “inhumane and degrading treatment and (re)constructions are a medicalization of social problems,
(. . .) a form of gender discrimination that flies in the while bloodless treatments are not, they conclude that
face of human rights principles for women.”22 there is no relevant difference and, in any case, it is not
The proper way of action, therefore, is to empower obvious that social problems may not be solved through
women so that they are better able to resist virginity medical interventions.29 Many authors also notice that
control and hymen (re)constructions. Others do not performing a hymen (re)construction does not mean
dispute that requests for hymen (re)constructions that the physician agrees with the virginity rule and that
follow from patriarchal norms that discriminate a consequence of performing the surgery on a large scale
against females but give priority to the well-being of would be to undermine the rule.27–29 The previous argu-
the individual patient and her autonomy16,23–25 or have ment implies that hymen (re)construction should not be
other principled arguments pro operating that banned (presuming that society rejects the virginity rule).
36 Clinical Ethics 14(1)

Yet, one could also argue that offering hymen (re)con- peno-vaginal penetrative sexual intercourse could be
structions expresses support for the virginity rule and reduced by approximately 60%, circumcision is
therefore should be banned. Another argument, made increasingly promoted by international health agencies
by Juth and Lynøe, against a ban is that society is signal- as a global health strategy to prevent heterosexually
ing repudiation of the virginity rule by helping young transmitted HIV/AIDS. Although the WHO and
women to deceive its representatives.29 UNAIDS recommend “voluntary” circumcision and
to obtain informed consent, in the case of minors it is
only suggested to follow “local regulations.”38 While
Nontherapeutic male circumcision: the conclusiveness of the evidence on which the recom-
Genital autonomy and gender injustice mendation is based is disputed,39 mass campaigns have
Historically, circumcision—the surgical removal of been set up to promote and offer male circumcision for
some, or all, of the foreskin—is found among different free, predominantly in the sub-Saharan region.
religious, cultural, and geographical communities.30,31 Meanwhile, some studies point to the adverse impacts
Although the practice dates back to Ancient history, it of circumcision, indicating how it enhances sexual risk
became rapidly medicalized during the 19th and 20th behavior,40 entails higher complication rates than pre-
century, especially in Anglo-Saxon countries, where it viously accepted,41,42 and long-term adverse effects on
was initially recommended to prevent masturbation sexual functioning, such as decreased sexual pleasure,
and sexually transmitted diseases such as syphilis.32 lower orgasm intensity, discomfort, and pain.43 Even
In countries like the US, where neonatal circumcision when the surgery is performed in sterile settings by
became routinely performed, anticircumcision activists experienced professionals, complications, although rel-
challenged the surgery as medically unnecessary and atively low, can still be very serious, including the loss
potentially harmful.33,34 While the American of (a part of) the penis and even death.41,42
In contrast to an earlier wave of bioethical debates
Academy of Pediatrics (AAP) no longer recommends
that mainly focused on neonatal circumcision in coun-
routine neonatal circumcision, it considers the surgery
tries like the US, male circumcision is now also increas-
to be a low risk procedure that helps to prevent urinary
ingly debated in Europe, in the context of politicized
tract infections, acquisition of HIV, and transmissions
debates on multiculturalism and religious accommoda-
of some STIs and penile cancer—a rare, but deadly
tion.44 In 2001, following a case where six asylum-
disease. Because circumcision in infancy is associated
seeking Bosnian boys were circumcised in a reception
with fewer complications, the AAP recommends that
center and became badly infected, Sweden was the first
the surgery should be available upon parental
to adopt a legislation that restricted the legality of cir-
request.35 In response to the AAP statement, physi- cumcisions of minors to those who were performed by
cians from different European countries, however, a licensed doctor.45 In 2010, the Dutch Federation of
declared that the assessment of evidence and the Physicians declared that the circumcision of boys was
policy statement of the AAP had a cultural bias: if in conflict with the rights of the child, and recom-
infant circumcision would not have been such a mended that surgeries should only be allowed when
widely accepted practice in the US, benefits and performed by a medical doctor.46 In 2012, in consider-
harms would have been assessed in a very different ing the case of a four-your-old Muslim boy whose
way.36 These critiques do not dispute that circumcision circumcision had resulted in complications, a German
confers certain health benefits, but question whether district court in Cologne declared that nontherapeutic
these can possibly justify infant circumcision or instead circumcision of minors was unlawful offence.
would, from a medical standpoint, require the boy’s The ruling initiated fierce protests, especially from
consent. As Frisch and Earp37 explain: Jewish and Muslim communities. Some spokesmen
denounced the court’s ruling as an act of anti-
(. . .) the question is not whether certain health benefits Semitism47 and Germany responded to the protests
may in fact ensue from the sheer surgical removal of by adopting a law that explicitly allows for religious
the foreskin, but whether, in light of alternative, less circumcision on parental request, including its perfor-
invasive, means of achieving the same desired health mance by nonmedical practitioners.48 Yet, also in 2013,
outcomes, the benefits are sufficient to outweigh the the Parliamentary Assembly of the Council of Europe
costs, harms, and other disadvantages (i.e. ‘risks’), adopted a resolution concerning “Children’s Right to
some of which may be subjective in nature and there- Physical Integrity” in which circumcision of young
fore difficult to quantify. boys is considered as a violation of the physical
integrity of children, comparable to female genital
Yet, in the past decade, based on three studies that mutilation and early childhood medical interventions
indicated that a man’s risk of contracting HIV through on intersex children.49 The statement evoked fierce
Coene and Saharso 37

criticisms from minority groups and, in a later resolu- Concerns about the protection of the genital integ-
tion, the Assembly stresses that there is no consensus rity of children have also been fed by a growing oppo-
among Member States on circumcision and recom- sition to so-called normalization surgeries performed
mends not to allow ritual circumcision of children on intersex children. While such surgeries are medically
unless it is practiced by trained and skilled persons, nonindicated, they are medically performed to make
in appropriate medical and health conditions.50 In intersex children fit into the strict gender binary.56,62
2017, the Belgian Advisory Committee on Bioethics Whereas female, male, and intersexed genital altera-
issued an advice to no longer refund the surgery by tions are increasingly problematized from a children’s
public social security.51 In 2018, a bill is proposed in rights perspective,63 circumcision of male adults or
Iceland to ban male circumcision.52 minors that are able to consent is largely perceived as
In political discourses and scholarly debates, male unproblematic and is even recommended as a valuable
circumcision is frequently compared with female geni- alternative.64
tal cutting/mutilation (FGC/M).53,54 The international
community considers FGM/C as a violation of human
rights, gender-based violence, and a form of child Discussion: Autonomy, beneficence,
abuse. According to the WHO, all surgeries that nonmaleficence, and justice
involve the partial or complete removal of external In the debates on hymen (re)construction that were
female genitalia as well as other injuries (like pricking, previously revised, two, or three, positions can be dis-
piercing, incising, scraping, and cauterization) are tinguished. While all agree that the request for a hymen
harmful to the health of women and a form of (re)construction is inspired by a patriarchal norm,
gender-based violence.55 The WHO considers male cir- some believe that hymen (re)construction should there-
cumcision and FGM as substantially different: while fore not be performed, whereas others believe that it
FGM is seen as a manifestation of deep-rooted may be performed, because the woman’s well-being
gender inequality and linked to a reduction in
and autonomy are paramount. This, however, should
women’s sexual desire and an irreversible loss of their
always be combined with counseling to make women
capability for sexual functioning, male circumcision, on
aware of this patriarchal norm.14,24 Furthermore, some
the other hand, is mainly associated with health bene-
believe that at the same time public measures should be
fits and considered as a gender neutral and nondiscri-
taken aimed at cultural reform of the minority groups
minatory practice.38 Nevertheless, as a number of
in question.4,23 Yet, a common argument that is raised
studies point out, there is often a symbolic overlap in
is that requests for hymen (re)construction are inspired
meanings and rationalizations of female and male gen-
by a patriarchal norm that infringes on women’s
ital cutting.56 Although it is difficult to generalize about
autonomy. Request by women to restore their hymen
the meanings of male circumcision, it cannot be
ignored that it is not a gender neutral practice, but is perceived as not truly autonomous and counseling is
one that often serves to establish manhood and male therefore recommended. The counseling practices
power and thus maintains patriarchal relations, oppres- that were reported in the literature, however, far
sive gender norms, and hierarchies.57,58 With regard to extend the usual conditions of informed consent.
harmfulness, some types of FGM/C—particularly In the Netherlands, the guideline of the Dutch
those that are considered under type 4—are also less Society of Obstetrics and Gynecology gives detailed
physically harmful than male circumcision. Yet the instructions about what the counseling should entail:
former are criminalized, while the latter are unregu- informing the patient about her body; if necessary with
lated.59 In identifying harmful cultural practices as the use of a mirror, find out about the meaning of vir-
practices that only negatively affect girls and women ginity for her, her partner, and their families; if possible
(predominantly in the South), human rights discourses draw the partner into the counseling, and check on
have largely neglected that boys and other genders risky sexual behavior, incest, and trauma that may be
could also be harmed by cultural practices. Some covered up or aggravated by the procedure. Although
authors therefore claim that the unequal human counseling can be perceived as enhancing the autono-
rights and legal recognition of physical and sexual my of the patient, it can also be used to influence
integrity of girls and boys constitute in itself a form patient’s decisions imposing upon them other values
of gender injustice.53,60 Yet, some draw attention to and norms.65 In debates on abortion, counseling
similar harms and meanings of female and male genital requirements were often opposed by feminist as they
cutting in in order to advocate a more repressive were perceived to aim at changing women’s minds,
approach of male circumcision53 while others use the create feelings of guilt, and undermining women’s
comparison to endorse a more tolerating approach right to decide.66 We notice, further, that in the debates
of—less harmful—forms of FGM/C.61 on hymen (re)construction the surgery is not compared
38 Clinical Ethics 14(1)

to arguably harmful cultural practices in the West, like rare. Yet, harms and risks of male circumcision have
cosmetic surgery, which pose comparable questions remained unrecognized for a long time, because of the
around autonomy and choice.67–69 cultural acceptance of the practice and its gendered
Furthermore, in debates on hymen (re)construction, meanings, including the endurance of pain as a sign
harm comes to mean social and physical reprisals, like of physical strength and manhood.57,58
being expelled from home or being murdered, and well-
being the absence thereof. Hymen (re)construction to
Conclusion
enhance self-worth is only discussed in the case of rape
victims. The idea that other motives but fear, like a Autonomy and bodily integrity are values that are pro-
desire to be part of a community or to express a cul- tected by law, human rights instruments, and medical
tural identity might inspire the requests, is virtually ethical standards. Therapeutic interventions require
absent. This is also reflected in the common argument informed consent, where possible, by the person her-
that there is no medical indication for hymen (re)con- self. In the case of adult persons, autonomy is seen as a
struction. Medical need is then reduced to illness, standard condition, which implies that persons should
injury, or physical impairment, hence, resting on a bio- be regarded as capable of making autonomous deci-
logical understanding of health. sions, unless a person is severely mentally handicapped
In contrast, the reasons to request for a nonthera- or suffers from a psychiatric disease that deteriorates
peutic male circumcision, whether by parents or the this capacity. Where minors are concerned, there is also
persons themselves, are generally not questioned. a growing tendency to respect their capacities for
Ethical issues mainly arise on the conditions of proxy autonomous decision-making. In the case of very
consent: as young children cannot decide for them- young children, parents or legal guardians are sup-
selves, parents or legal guardians are supposed to act posed to decide in the best interests of the child.
in the best interests of the child and to give their con- Opinions on what is in the best interests of the child
sent to medical treatment, yet their decisions may not diverge, as these are based on socio-cultural values and
put the physical health, well-being, or life of the child in meanings. With regard to nontherapeutic surgeries,
danger. Since health benefits only become relevant later difficult questions therefore not only arise on how to
in life while the surgery entails pain, discomfort, risks balance harms and benefits, but also on what counts as
for complications for the child and is irreversible, non- relevant to assess harm and well-being. What counts as
therapeutic infant circumcision is not justifiable for bodily harm and well-being cannot be disconnected
mere health preventive reasons. Yet, children’s well- from personal values, social meanings, and cultur-
being does not only involve physical concerns. To be al identities.
part of a community, to be able to express a religious or Yet, this recognition is also behind the demand for
cultural identity, and to experience social acceptance informed consent and patients’ rights to decide for
and positive self-worth are also important and are themselves. However, when young and adult women
largely accepted to justify other medically nonindicated ask for a hymen (re)construction, this is often refused
surgeries on children. Cosmetic and corrective surgeries or only performed after extensive counselling. By con-
are seen as justifiable if they are in the child’s best, trast, requests for male circumcision by adults or
immediate or future, interest. However, as is for minors who have the maturity to understand the impli-
instance argued in the case of “normalizing” surgeries cations of a procedure are not problematized. Thus,
of intersexed children, what is considered to be in medical paternalism apparently only comes up with
the child’s best interests can also rely on oppressive regard to women’s requests, and more particularly
gendered norms.56 those of migrant women.
In the case of hymen (re)construction, it is often As both concern genital surgeries, they bring gen-
argued that the operation should only be performed dered and cultural assumptions about the sexual body
if the women fear violence and physical sanctions, to the foreground. Male circumcision is more culturally
such as honor killings. However, hymen “repair” can acceptable in western countries whereas hymen repair
spare the young woman in question a lot of psycholog- is almost exclusively conceived as an issue of immigrant
ical and social suffering, like shame or not being able to minorities, and Muslims in particular. Hymen (re)con-
marry. While male circumcision may not have the same struction is problematized from a women’s rights per-
effect in terms of becoming exposed to physical vio- spective and condemned as stemming from patriarchal
lence or honor killing, there is also a huge social norms. Male circumcision is seldom discussed from a
pressure to perform the surgery. Furthermore, there gender perspective, and although increasingly problem-
is hardly any evidence on medical complications to atized from a children’s rights perspective, circumcision
temporary hymen suture, and while hymenoplasty is of adults and older boys is also increasingly suggested
a more invasive technique, medical complications are as an acceptable alternative. It thus seems that
Coene and Saharso 39

autonomy and bodily integrity are regarded as suffi- 10. Thornberry E. Virginity testing, history, and the
ciently protected by the informed consent of the patient Nostalgia for custom in contemporary South Africa.
in the case of circumcision, but not in the case of Afr Stud Rev 2015; 58: 129–148.
hymen (re)construction. 11. Wei SY, Li Q, Li SK, et al. A new surgical technique of
hymenoplasty. Int J Gynaecol Obstet 2015; 130: 14–18.
12. Loeber O. Over het zwaard en de schede; bloedverlies en
Declaration of Conflicting Interests
pijn bij de eerste coı̈tus Een onderzoek bij vrouwen uit
The author(s) declared no potential conflicts of interest with diverse culturen. Tijdschr Seksuologie 2008; 32: 129–137.
respect to the research, authorship, and/or publication of 13. Loeber O. Wrestling with the hymen: consultations and
this article. practical solutions. Eur J Contracept Reprod Health Care
2015; 20: 128–135.
Funding 14. Van Moorst BR, van Lunsen RH, van Dijken DK, et al.
Backgrounds of women applying for hymen reconstruc-
The author(s) disclosed receipt of the following financial sup- tion, the effects of counselling on myths and misunder-
port for the research, authorship, and/or publication of this standings about virginity, and the results of hymen
article: The research was supported by a sabbatical grant for reconstruction. Eur J Contracep Reprod Health Care
the first author of the Flemish Research Foundation, FWO. 2012; 17: 93–105.
15. Gürsoy E and Vural G. Nurses’ and midwives’ views on
ORCID iD approaches to hymen examination. Nurs Ethics 2003;
Gily Coene http://orcid.org/0000-0002-8158-0718 10: 485–496.
16. Cook RJ and Dickens BM. Hymen reconstruction: ethi-
cal and legal issues. Int J Gynaecol Obstet 2009;
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